HomeMy Public PortalAbout5700-5702-5704 NOEL DR_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
Insure arta certificate of Workers Compensation Insurance �� HEATING - VENTILATING AIR CONDITIONING
or a ce�fied copy thereof(Sec 3800 Lab C)
AP CE 818(REV 10/81)
Poky No Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN FBUILDLINGtion department (PRINT OR TYPE ONLY)Date Applicant CERTIFICATE OF EXEMPTION FROM WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEENEAREST
COMPENSATION INSURANCE CROSS ST
(This section need not be eomplefed If the work Involved by ABSORPTION UNIT BTU DISTRICT NO PROCESSED BY
the permit Is for one hundred dollars(:100)or less)
1 certify that in the performance of the work for which this AIR HANDLING UNIT CFM
permit is Issued I shall not employ any person in any manner
so as to become subject to the Workers CompensationLaws BOILER BTU APPROVALS DATE 1 PE iGN RE
Date pelican COMPRESSOR BTU ROUGH
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers ZI
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAUGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business HEATER WALL
and Professions Code and my license is in full force and effect d
qd s
License Number is Class ® ► V
001,
Contractor ® Date 90
T �O
❑ I am exempt under Sec cog:::,
Plan check fee
B 8P C for this reason Us
PERMIT ISSUING FEE$ Z
Date
Signature TOTAL FEE
0 3 2 8 A
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License , # e • • • • 8
Law for the following reason (Section 7031 5 Business and NAME
Professions Code)
❑ I as owner of the property or my employees with ADDRESS 4 Q 5 0
wages as their sole compensation will do the work and CITY TEL NO • -i-•4 Q5 0 c=T
the structure is not intended or offered for sole(Section
17044 Business and Professions Code) OWNER
ElI as owner of the property am exclusively contracting 01 $8
with licensed contractors to construct the project (Sec MAIL
tion 7044 Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CITYGv� TEL NO ,?q
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR
(Sec 3097 Civ C )
ADDRESS
Lender s Name
CITYTEL N / �G
Lender s Address
STATE LIC Q
1 certify that I have read this application and state that the LICENSE NO CLASS _
above information is correct I agree to comply with all County
ordinances and State laws relating to building construction
and hereby a thorize repr ntatives of this County to enter "
upon a ab a me property for Inspection urp es SEE REVERSE FOR EXPLANATORY LANGUAGE
r
Signature of Applicent or Agent—,;/00- Date